IMPAIRED MEMORY LOSS
ASSESSMENT
SUBJECTIVE
“I forgot things sometimes” as
verbalized by the patient
OBJECTIVE
 Forget to perform a
behavior at a scheduled
time
 Inability to learn/ retain
new skills/ information
VITAL SIGNS
DIAGNOSIS
Impaired memory loss related to
Neurological disturbances
PLANNING INTERVENTION RATIONALE EVALUATION
Patient will verbalizes awareness Independent
of memory problem
 Orient/ reorient client as  To meet client’s safety
needed. Introduce self and comfort needs
with client contact
 Note client’s age and  Depressive disorders
potential for depression affecting memory and
concentration are
particularly prevalent in
older adults; however,
impairments can occur
in depressed persons of
any age
 Ascertain how patient  To determine
family view the problem significance/ impact of
the problem
 Encourage ventilation of  To diminish feelings of
feelings of frustration, powerlessness/
helplessness. Refocus hopelessness
attention to areas of
control and progress
 Assist with treatment of  Where treatment can
underlying conditions improve memory
process
 Provide for/ emphasize  To avoid fatigue that
importance of pacing may further impair
learning activities and cognitive abilities
getting sufficient rest
Dependent

 Determine client’s  Medication for cognitive

response/ effects of enhancement can be
medications prescribed effective but benefits
to improved attention, need to be weighed
concentration, memory against whether quality
process and to lift of life is improved when
spirits/ modify considering side effects/
emotional responses cost of drugs

 Assist with/ review  To complete picture of

results of cognitive client’s overall condition
testing (BIMC – Blessed and prognosis
Information Memory
Concentration) test,
(MMSE – Mini-Mental
State Examination)
RISK FOR INJURY

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE
“ I am experiencing difficulty in
recognizing things” as verbalize
by the patient
Risk for injury related to unable
to recognize/ identify hazards in
environment as possible
evidence by falls or
disorientation
Patient verbalize understanding
od individual factors that
contribute to possibility of injury
Demonstrate behaviors, lifestyle
changes to reduce risk factors
and protect self from injury
INDEPENDENT
 Perform thorough  Failure to accurately
assessment regarding assess and intervene or
safety issues refer these issues can
place the patient at risk

 Ascertain knowledge of  To prevent injury

safety needs/ injury
prevention and
motivation

 Note: client’s age,  Affects the client ability

gender, developmental to protect self and/
stage, decision-making others, and influences
ability, level of choice of teaching
cognition/ competence

 Assess mood, coping  May result in

abilities, personality carelessness/ increased
lifestyle risk taking without
consideration of
consequences

 Assess client’s muscle  To identify risk for falls

strength, gross and fine
motor coordination

 Identify interventions/  To promote safe

safety devices physical environment
and individual safety

 Discuss importance of  That can contribute to

self-monitoring of occurrence of injury
conditions
 Perform home  To prevent client from
assessment/ identify wondering off while SO
safe issues, such as is engaged in other
locking up medications/ household activities
poisonous substance

 Identify individual needs  For safety education

 Administer medications
and infusions using 5’R
(5 rights) system

RIGHT PATIENT
RIGHT MEDICATION
RIGHT ROUTE
RIGHT DOSE
RIGHT TIME